All Saints Vicarage

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People were protected from the risk of harm and abuse by staff who were knowledgeable and knew how to report concerns. Risk assessments were in place and regularly reviewed. Staffing levels were in line with people’s assessed needs and safe recruitment practices were followed. Work was being completed to develop the culture of the home based on mutual support, openness and honesty.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People, and their families were involved in developing care plans and risk management plans. There was evidence of a learning culture, and work was being completed to embed good practices following the receipt of a complaint about care needs and actions taken at the home. Managers now attended the shift handover each morning, so they were aware of the circumstances in the home.

Some staff felt the culture of the home was positive and open whilst others said they did not feel listened to or supported. We shared this with the registered manager who said the provider had instigated an independent review of the home. This made several recommendations which were being actioned in relation to the manager’s approach and visibility, as well as staff understanding of processes. In addition, culture workshops were due to take place to support all staff, including the managers, to develop a shared vision and culture.

Lessons were learned when things went wrong. Safeguarding matters were reported to the local authority and CQC, as required. Investigations were completed following significant issues and improvements made. Complaints were documented and appropriate action taken. There was evidence of disciplinary processes having taken place. Staff meetings were held regularly. Minutes tended to suggest this was a management lead process, although there was the opportunity for staff to raise any issues. Accidents and incidents were recorded, and action taken to mitigate future issues. The provider had a whistle blowing policy and an independent phone number staff could contact to raise concerns. A copy of the contact details were on one of the home’s notice boards.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were protected from the risk of harm and abuse. Staff focused on supporting people to live meaningful and engaging lives.

Staff understood safeguarding procedures, had access to policies, and said they were confident concerns would be acted on. Leaders offered assurances that safeguarding concerns were managed appropriately and the concerns raised in relation to culture had not had any impact on people.

Staff were observed to engage appropriately with people, and we did not see any concerns.

Processes were followed to ensure safeguarding concerns were raised appropriately. Action had been taken to investigate concerns, learn lessons and mitigate risks. Care records detailed people’s presentation, if they were becoming anxious or distressed, and how this could be effectively managed and de-escalated. Staffing levels were such that people were protected from the risk of harm, as far as possible.

People’s families were very involved in their loved one’s care and had been included in discussions around care plans, risk assessments and reviews. However, one relative said they didn’t think they had seen a care plan.

Staff said they were able to meet people's needs, whilst managing risks. They said people and their families were involved in managing risks in a way which supported people to do the things they enjoyed. The registered manager acknowledged the need for open, honest, and transparent conversations with parents and involvement in best interest’s decision making.

Everyone living at the home had one to one support during the day and staff were observed supporting people with a range of activities. The environment was minimalistic. However, this supported the positive management of risks due to people’s needs.

Risk assessments were in place and staff had a good understanding of the risks people faced and how to manage them. Positive behaviour support plans identified behaviours which indicated people were having a good day, or where they may be anxious or distressed. The actions staff needed to take to help support or mitigate risks associated with distressed behaviour were detailed. Records detailed any health conditions people may be living with. Staff were aware of these and knew how to support people.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Relatives felt there were enough staff, however some commented on changes to the staff team due to people leaving, meaning they did not have the same relationship with newer staff. Some relatives also commented on some language barriers but on the whole said their loved ones got on well with staff, who knew them well and provided safe care. The provider had plans in place to support the staff team to develop positive working relationships.

Most staff felt there were enough staff to meet people's needs. However, some said people would benefit from more staff who could drive and more female staff. The registered manager said they were aware of this and had been working to resolve it through ongoing recruitment. Staff said they had all the training they needed to enable them to support people safely, however, there were mixed views in relation to support and supervision. The registered manager was aware of this and was working to address it.

There were enough staff to meet people’s needs. Everyone living at the home had 1:1 staffing for at least 12 hours per day. Some people had increased staffing when going out in the community or attending appointments. We observed staff were allocated on a 1:1 basis and did not seem overly stretched or unable to cope. People were supported to go out and participate in activities in the community.

Safe recruitment practices were followed. Appropriate pre-employment checks were completed including interviews, references, DBS checks and right to work processes. Supervision and appraisals were completed; however, staff wellbeing was not always well documented. There was some evidence staff were able to reflect on their experiences and actions were noted for development. The registered manager told us they were in the process of reviewing the quality and effectiveness of supervision, to ensure staff felt valued and listened to.

People lived in a home which was clean and tidy, with no malodours. Relatives said some areas needed redecorating. This was being completed gradually throughout the home.

Some staff commented they felt dedicated cleaning staff and a cook would be an improvement, however, didn’t share any concerns in relation to infection prevention and control (IPC). The registered manager was aware of staff views and said some people living at the home were being supported by staff to learn new skills and increase their independence. They added it was an area which was discussed regularly at team meetings.

Staff were observed to wear Personal Protective Equipment (PPE) appropriately and when needed. People’s bedrooms were often minimalistic due to nature of people’s presentation but were clean and tidy. One professional told us, “It doesn’t look like a wonderful fluffy home, but it is as appropriate as it can be for the client group. Plus, they now have the allotments for people to grow vegetables. They have really good outside space.”

The majority of cleaning in the communal areas of the home was carried out by night staff who did not think this was onerous. IPC audits were completed, and an IPC policy was in place. The recording of fridge temperatures was not well documented and the cleaning schedule for the kitchen had some blanks, however, no concerns were identified during the inspection and items were stored properly in the fridge.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.